NONSTOP CRISIS MODE
A 24/7 Phoenix methadone clinic is overrun by clients desperate to escape grip of opioids
People desperate to give up opioids are flocking to a bursting-at-the-seams methadone clinic in north Phoenix in such large numbers that clinic leaders are adding locations to handle the demand.
But the soaring client numbers have the clinic’s neighbors pushing back over the crowds of people and cars at the facility.
At one point in June, the 5,300-square-foot Community Medical Services clinic at 2301 W. Northern Ave. saw a record 1,400 patients in one 24-hour period, clinic leaders say.
The surge in patients over the past nearly 16 months coincided with a single change at the clinic, which has been operating at the same spot for more than five years. On Oct. 1, 2017, with the help of a federal grant, the clinic became the first 24/7 medication-assisted treatment center in Arizona.
The expanded clinic hours have been a key, said Nick Stavros, chief executive of Community Medical Services, a for-profit company based in Scottsdale.
“For some reason, this clinic has started engaging people who otherwise would not have gotten into treatment. That’s why I think it exploded . ... I really think this model should be replicated,” he said.
Stavros said the company is adding satellite locations to better handle the demand and is working to build better relations with its neighbors, who have been rattled by the increase in business.
The clinic creates what state Sen. Kate Bro-
phy McGee, R-Phoenix, called “a mass assemblage of very vulnerable people” who are easy prey for drug dealers, even though they are trying to get well, she said.
Brophy McGee said the issue is balancing the safety and security of the neighborhood with the safety and security of the patients.
Opioid overdoses are killing at least two Arizonans per day, and methadone is a scientifically proven way of treating opioid addiction.
Medication-assisted treatment, combined with counseling, is considered the “gold standard” for treating opioid-use disorder, said Beth Connolly, who directs the substance abuse prevention and treatment initiative at the Pew Charitable Trusts.
Methadone is one of three FDA-approved medications for opioid-use disorder, Connolly said. The others are buprenorphine (Suboxone) and naltrexone (Vivitrol).
Access to medication-assisted treatment is a problem nationwide, and methadone is more highly regulated than Suboxone or Vivitrol. By law, methadone may only be dispensed through an opioid treatment program certified by federal Substance Abuse and Mental Health Services Administration.
Of the 13,749 substance-use disorder treatment facilities in the United States, fewer than half offered MAT services in 2018, and only 3 percent made all three MAT drugs available, Connolly said.
Tucson now has a 24/7 MAT facility. But other than the two in Arizona, Connolly said she knows of no 24/7 MAT facilities in the U.S.
“When people are ready to seek treatment, having treatment available to them at that moment is very important,” she said. “We really would like to see an increase in medication-assisted treatment because we know it is effective.”
How the treatment program works
Clients at Community Medical Services may receive methadone, Suboxone or Vivitrol, depending on their needs, but a majority of the people who use the Community Medical Services clinic on Northern are getting daily methadone doses as a way of weaning themselves off opioids.
“We know it takes someone’s brain about two years to heal from heavy opioid use. Putting them through a 28day residential, putting them through detox — it doesn’t faze them. There’s this revolving door. Until you get them on MAT in a maintenance program, they don’t stop going through the revolving door,” Stavros said.
“About half our patients have been going through the revolving door. The other half are just new to treatment.”
Since methadone is so strictly regulated, clients must show up at the clinic daily to get their dose. Some may earn the privilege of take-home doses after a period of treatment, but in-person dosing is by far the most common way patients get the drug, commonly administered in a bitter-tasting pink liquid form.
Methadone is an opioid replacement that lessens the painful, nausea-inducing symptoms of withdrawal and reduces cravings while blocking the high that people normally get from using opioids like heroin and morphine.
It has been used for decades as a treatment for people who are addicted to heroin and other opioids.
The problem with opioids the general public doesn’t always recognize is that while there’s an initial high, it eventually wears off. People get hooked because they need the opioids to not feel awful. It’s not about getting high. Rather, it’s about trying to feel less horrible.
But methadone also is an opioid and causes physical dependency, which is why it must be taken exactly as prescribed. Under federal law, methadone may only be dispensed through an opioid treatment program certified by the Substance Abuse and Mental Health Services Administration.
In addition, federal law requires patients who receive treatment in an opioid treatment program to receive medical, counseling, vocational, educational, and other assessment and treatment services.
Key to the Community Medical Services program is peer support that clients receive from others who are in recovery.
Stavros said patients can expect to be in treatment for about three years before weaning off methadone, though that time varies for each person.
“This is prescribed like other medications would be, under the care of a doctor,” said Connolly of the Pew Charitable Trusts. “Some people stay on all types of medications for years — medications for hypertension, for high cholesterol. Medication for a substance-use disorder is no different . ... Substance-use disorder is a chronic disease.”
‘They could get me in right away’
Community Medical Services leaders quickly discovered that offering roundthe-clock access brought in a swell of patients such as Amber Stewart, a 39year-old Glendale resident and married mother of three who had tried and failed to get off heroin and prescription painkillers numerous times.
“They could get me in right away,” Stewart said. “Other places I called
would tell me I had to wait, and then I would go back to heroin.”
It’s what clinic workers call the “moment of hope” factor.
The biggest barrier for people trying to quit opioids, including heroin, is how sick they feel when they don’t get the drug.
While going cold turkey might sound like a better route than replacing it with another drug, it often doesn’t work. And in pregnant women, going cold turkey from opioids can compromise the baby.
“Most people don’t use heroin to get high. They use it to stave off withdrawals,” Stavros said.
Giving up heroin without an opioid replacement didn’t work for Stewart.
Without heroin, she’d start sweating and shaking, and the only way she believed she could function and take care of her family was to use more.
“I’d been to several other clinics in the Valley. I always relapsed,” said Stewart, who had a $600 per week heroin addiction before getting help. “Community Medical Services could get me in right away. At the other places, you often had to wait.”
The clinic allows people to come in even if they are high, gives them time to wait for the high to wear off, and can then start them on the dose of medicationassisted treatment that best suits their needs — all during the same visit.
For most patients, including Stewart, that’s methadone.
A majority of the patients who use the Community Medical Services clinic are between the ages of 25 and 44. But the clients cover a wide age range, from age 18 up to senior citizens.
Still, public confusion and misunderstanding about MAT for opioid-use disorder is still keeping some people away, Stavros said.
“Methadone needs a rebranding. It is a terrible name,” Stavros said. “When this whole thing blew up (with the neighborhood), I can’t tell you how many calls I got from people thinking we were a meth lab. I’m serious. They’d say, ‘You guys are just providing meth to people.’”
Clinic adds satellite locations
Community Medical Services has more than 500 employees and operates 29 clinics in nine states. Clearview Capital, which has a history of investing in health care, holds majority ownership of the company.
A few months after going 24/7, Community Medical Services clinic leaders found themselves scrambling to open satellite locations to handle demand. In July, they opened a satellite clinic in Glendale. Late last year they opened another satellite location on North 27th Avenue near West Campbell Avenue.
The clinic is choosing its satellites based on the addresses of existing clients at the Northern Avenue location. Already, 1,000 patients from Northern Avenue have been sent to the satellites, Stavros said.
The largest portion of the Northern Avenue clinic’s clients come from the Sunnyslope area. Community Medical Services had hoped to open a clinic there too, but plans are on hold while the company works to alleviate neighborhood concerns.
“It has just exploded,” Stavros said of the client volume. “There’s just an extreme shortage of treatment. The system itself is strained, not just our clinic. We’re trying to open clinics, transition patients to other clinics. We cannot just keep intaking 250 (new) patients a month here indefinitely. It’s not slowing down.”
Neighbors: It’s not a ‘NIMBY’ issue
The people who frequent the Community Medical Services clinic often arrive on foot, by bus or via cars.
The parking lot, which is under constant surveillance by an off-duty police officer and at least one traffic navigator, is frequently crowded with cars and people. For anyone passing by, the constant activity is hard to miss.
About 90 percent of clients at the Community Medical Services clinic are covered by Arizona’s Medicaid program, the Arizona Health Care Cost Containment System. which pays for medication-assisted treatment.
Patients whose insurance doesn’t cover MAT may pay cash for $65 per week, which includes medication, counseling, labs and other behavioral support, Stavros said. The clinic doesn’t turn away any new patient intakes, he said.
Clinic leaders say they’ve heard criticism from people who assume that a population addicted to opioids is going to bring with them higher crime rates. But the people going to the clinic are trying their best to get their lives back on track, Stavros said.
The clinic always has security guards both inside and outside, he said.
The pushback is largely about the fact that the clinic is simply too small, said Brophy McGee, who has been working to address complaints with a group she formed in June called the 23rd Avenue and Northern Neighborhood Preservation Task Force.
Brophy McGee, chairwoman of the Arizona Senate’s Health and Human Services Committee, pointed to the 24/7 MAT clinic in Tucson as an example of one that seems to be working well, without the neighborhood criticism the Phoenix clinic has attracted.
The Tucson clinic, operated by CODAC Health, Recovery and Wellness, is 21,000 square feet, which is more than three times the size of the Phoenix clinic, though the Phoenix clinic recently purchased a 3,600square-foot building next door.
The problem with the Community Medical Services clinic is that it backs straight up into a neighborhood with no buffer and the parking lot is inadequate, Brophy McGee said.
“The building is too tiny, and it’s too close to the neighborhood,” she said. “To me, it’s promises made and not being kept over and over again,” Brophy McGee said.
“This is not about being a NIMBY. All the people on this task force have either a loved one, a friend or a neighbor involved with addiction, even to the point of losing a loved one.”
Jeff Spellman, a member of Brophy McGee’s task force, has lived in the neighborhood for 35 years. He said that after the clinic went 24/7, there was an increase in transient and petty crime in the neighborhood. In the past year, he has added security cameras at his home, which is about a half-mile from the clinic.
“There’s been a huge, drastic increase in what I call criminal transients in the area. I’ve had people coming into my backyard,” Spellman said. “We’ve had people passing out in front of restaurants and other businesses. This is stuff we are seeing and didn’t used to see. We blame much of it on the clinic.”
Spellman said there are federal guidelines that require interaction between clinics and neighborhoods
before opioid treatment programs move in. That didn’t happen before the Northern clinic went 24/7, and there needs to be a structure in place to improve communication between opioid treatment clinics and neighborhoods, he said.
“We don’t just want to move problems out of the Northern clinic and into other areas,” Spellman said. “We have talked to Senator Brophy McGee about it and are hoping it will be a priority for her in this session.”
The clinic has its supporters as well. Haley Coles is executive director of Sonoran Prevention Works, which is a Phoenix-based non-profit that aims to reduce barriers for people affected by substance-use disorder.
“This is one of the only 24/7 MAT clinics in the entire country. The entire country is looking to them (Community Medical Services) for their leadership,” Coles said.
“And then you’ve got this neighborhood group that wants to shut it down and frankly doesn’t care about its community members dying without that treatment.”
Addiction is not a choice
John Koch, the clinic’s community impact manager, and other clinic staff members regularly participates in neighborhood clean-ups with Community Medical Services clients as a way of trying to bolster the clinic’s image.
“If there is something to change, it’s the stigma of people with addiction,” Koch said. “Before they walk into this place, they’ve probably been told they don’t matter.”
Addiction is not a choice, he said, and the people who go there are sick.
“Nobody wakes up saying I want to hate myself, lose my kids and have my family hate me,” Koch said.
Koch, 30, knows that feeling firsthand. He said he grew up in an affluent suburb of Chicago in a stable family, but he started using opioids at age 14.
By 16, he was injecting heroin because it was easier and cheaper to get than prescription drugs.
“My parents live in a half-milliondollar home, but I ended up homeless. The streets are where addiction took me,” said Koch, who has since turned his life around. He recently got married, bought a house, works at the clinic and is studying business.
Stavros also has experience with the toll of addiction: His sister died of a heroin overdose when she was 21.
He constantly thinks back to what he could have done to get her to stop. A lot of time, people with addictions aren’t going to respond, but he firmly believes methadone is a realistic option for recovery.
“Methadone is not addictive. It causes physical dependency, but a dependency is not the same as an addiction,” he said. “An addiction is when you keep doing something in spite of negative consequences. If you are receiving methadone, you can have a job, be reunited with your friends and family and contribute to society.”
Someone with a substance-use disorder taking methadone is no different
than a diabetic needing to take insulin to replace what their body isn’t producing, Stavros said.
Patients credit recoveries to the clinic
Amber Stewart has had people tell her the methodone dose she takes every day is a “free high.”
But it’s not that at all, she said. Without methadone, she would either be on heroin or be very sick and unable to function, she said.
On her second day of getting methadone at Community Medical Services, Stewart wanted to quit. She was shaking, panicking, sweating, feeling ill and desperate for heroin to help her feel better. But instead of going out and buying it right away, she told Koch how she was feeling.
He responded by praising her for being strong. “That’s when I just knew they’d help me,” Stewart said. “They’ve been supportive of me ever since. When you first decide to get clean, it is kind of hard to get up and get going. It takes a while to get stable.”
Stewart became addicted to painkillers after a car accident, and she resorted to heroin because it was cheaper and easier to get. But long before the painkillers, she’d had a problem with crystal methamphetamine, she said.
Like others who struggle with opioid-use disorder, Stewart had trouble with the law, and it was always connected with her drug use.
When she was found driving without a license and in possession of heroin, Koch offered to accompany her to the court date.
“No one has ever done that for me,” she said. “That was the beginning of my new life.”
She received two years’ probation and a chance to set her life on a better course. She’s now working to get certified as a peer-support counselor, so that she can offer others the kind of nonjudgmental support she had long needed and she said Koch gave to her.
Clinic doesn’t ‘make you feel worthless’
Lollice Reese, 54, said he is having success in giving up heroin with the help of Community Medical Services, too. Mostly, it’s because he never feels anyone is looking down on him, he said. Rather, they seem to value him, he said.
Reese is on federal probation for trafficking undocumented immigrants to support a drug habit.
Transporting the migrants from areas near the border paid between $1,000 to $2,000 per trip, which went a long way toward supporting his heroin addiction, Reese said.
“I never transported weapons or drugs,” said Reese, who takes daily doses of Suboxone to diminish his cravings for heroin.
Reese first sought medication-assisted treatment in February after a relapse. It was 11 p.m. He was ready to get help, and he’d heard good things about the clinic on Northern Avenue, so that’s where he went.
Reese stayed at the clinic for hours that night, and he was processed sometime in the early hours of the next morning. He instantly felt supported, he said.
“This is the longest I’ve been sober since 2000, other than when I was in prison, and sometimes I was not even sober then,” Reese said.
Reese’s mother was ill over the holidays and his stress level went up. His counselor at Community Medical Services has been helping him cope without going back to heroin.
Reese doesn’t want to go back to the days when he’d wake up “dope sick,” unable to keep anything down, shaking, and only able to feel better with more heroin.
He is working full time in construction, owns a car and lives with family members in a Valley home.
He also has plans: He’s hoping to get his commercial driver’s license and become a truck driver.
“I do feel if there was less judgment and more education about opioids, it would help,” Reese said. “If you are not clean and sober, eventually you are going to end up in jail. It doesn’t matter what kind of addiction. I’m tired of being incarcerated, and this clinic is what’s keeping me sober.
“They don’t make you feel worthless.”